Citation Nr: 21069048 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 17-44 250 DATE: November 17, 2021 ORDER Service connection for tinnitus is denied. Service connection for bilateral hearing loss is denied. Service connection for a disability manifested by severe cramps in the hands and legs is denied. Service connection for a respiratory disability (claimed as asthma) is denied. Service connection for a sleep disorder is denied. A total disability rating based on individual unemployability due to service-connected disability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran's tinnitus did not begin during or was caused by his period of service. 2. A bilateral hearing loss disability was not manifest during service or within one year of separation; bilateral sensorineural hearing loss disability is not attributable to noise exposure incurred during service. 3. The Veteran does not have a disability manifested by severe cramps in the hands and legs that had onset due to disease or injury incurred during a period of service. 4. The Veteran's preexisting asthma was not aggravated during his period of service and his current restrictive lung disease did not onset due to disease or injury incurred during a period of service. 5. The Veteran's current sleep apnea did not onset due to disease or injury sustained during his period of service and was not caused by or made worse by his service-connected irritable bowel syndrome (IBS). 6. The Veteran's service-connected disabilities preclude the Veteran from securing and following substantially gainful employment consistent with his work and education background. CONCLUSIONS OF LAW 1. The criteria to establish service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria to establish service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385. 3. The criteria to establish service connection for a disability manifested by severe cramps in the hands and legs have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria to establish service connection for a respiratory disability (claimed asthma) have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 5. The criteria to establish service connection for a sleep disorder have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 6. The criteria for entitlement to a TDIU have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to December 1974. These matters came before the Board of Veterans' Appeals (Board) on appeal from February and July 2016 rating decisions issued by the RO. In May 2019, the Board remanded the claims for medical examinations which were conducted in November 2019. The requested development has been completed. The appeal originally included the issue of service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety, bipolar disorder, and delusional disorder. In January 2021, the RO granted service connection for anxiety disorder effective October 7, 2015. The claim for service connection for an acquired psychiatric disorder has been resolved and is no longer on appeal. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second NOD must thereafter be timely filed to initiate appellate review of the claim concerning the compensation level assigned for the disability). Service Connection The law provides that service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities such as other organic disease of the nervous system (i.e., sensorineural hearing loss), are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As noted, other organic disease of the nervous system (i.e., sensorineural hearing loss) is a chronic disease. 38 U.S.C. § 1101. Therefore, section 3.303(b) is potentially applicable. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). Further, service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is also warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b); see also Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b). 1. Entitlement to service connection for tinnitus The Veteran asserts that his tinnitus began during his period of service and has been continuous since that time. The Veteran served on active duty as an aircraft hydraulic repairman. During a December 1985 VA general medical examination, there were no ear or hearing abnormalities noted. An October 2015 VA hearing loss and tinnitus examination report reflects the Veteran's report that he first noticed his tinnitus between April and June 1974 while he was working on the flight line while stationed at March Air Force Base. However, the Veteran's service treatment records belie his account of the onset of symptoms. They do not reflect any evidence supporting the Veteran's assertion. In his October 1974 pre-separation physical examination, the Veteran specifically denied then having, or ever having had, ear trouble and/or hearing loss. The Veteran also then specifically denied then having, or ever having had, "any illness or injury other than those already noted" otherwise on the questionnaire form (Question 20, Standard Form 93). The October 2015 VA examiner found that the Veteran's then-complaint of tinnitus was at least as likely as not associated with his hearing loss. As noted below, the Board is presently denying service connection for hearing loss. The November 2019 VA hearing loss and tinnitus examination report reflects the Veteran's report that his tinnitus began in 1973 while he was stationed at March Air Force Base. The audiologist opined that the Veteran's tinnitus was less likely than not caused by or a result of military but explained that tinnitus is a subjective complaint and can have many possible etiologies. The Veteran's tinnitus has been linked to a non-service-connected disorder and there is no credible evidence supporting the Veteran's assertion of service onset. The claim is therefore denied. Entitlement to service connection for bilateral hearing loss Specific to claims of service connection, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran asserts that noise exposure in service caused his bilateral hearing loss disability. Because there is no competent medical evidence that links the Veteran's hearing loss to his military service, the claim will be denied. The February 1973 enlistment examination audiological examination showed that the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 / 10 LEFT 10 5 5 / 10 The December 1974 separation audiological examination showed that the Veteran's Puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 10 5 0 5 LEFT 0 0 10 5 0 The service treatment records show no complaints or findings of hearing loss disability. However, that the absence of in-service evidence of hearing loss disability is not fatal to the claim, see Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of section 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In October 2015, the Veteran underwent a VA audiological examination which showed that the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 35 40 45 LEFT 20 25 30 35 35 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and 84 percent in the left ear. Thus, he demonstrated bilateral hearing loss disability for VA purposes. The audiologist opined that the Veteran's bilateral hearing loss disability was not at least as likely as not caused by or a result of an event in military service. The audiologist noted that the Veteran had normal hearing at separation from service with no significant threshold changes from the entrance examination and explained that a study by the Institute of Medicine (September 2005) stated there was no scientific basis for delayed or late onset noise induced hearing loss. The audiologist concluded that it was difficult to attribute the Veteran's recent hearing impairment functioning sole to the trauma sustained during military service and not consider other factors such as aging and noise exposure from occupational activities after military service. In the March 2019 remand, the Board found the October 2015 VA examination inadequate because of an internal inconsistency of the audiologist's opinion. The Board noted that the audiologist determined that the Veteran's bilateral hearing loss was not at least as likely as not related to his service because there was no significant threshold shifts in service and the medical literature did not support delayed onset of noise induced hearing loss. However, the audiologist also found that the Veteran's tinnitus was a symptom of his hearing loss and had onset during service (i.e., between April and June 1974 while the Veteran worked on the flight line at March Air Force Base). The Board explained that it was unclear how tinnitus is a symptom of hearing loss and was noted as experienced in service but the hearing loss was found as not experienced in service. Because of the internal inconsistency, the Board found the examination inadequate and remanded the claim for an adequate opinion. Accordingly, in November 2019, the Veteran underwent a VA audiological examination which showed that the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 35 35 40 45 LEFT 20 30 35 35 35 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 100 percent in the left ear. Thus, he demonstrated bilateral hearing loss disability for VA purposes The audiologist opined that the Veteran's bilateral hearing loss disability was not at least as likely as not caused by or a result of an event in military service. The audiologist explained that the service treatment records showed hearing was within normal limits with no significant shifts. The audiologist noted that the Veteran reported post military noise exposure as a sheet metal worker from 1979 to 1988. The audiologist concluded that there was no evidence to indicate the Veteran's bilateral hearing loss disability began in service or within a reasonable time after separation from active duty. Further, the audiologist acknowledged that the Veteran's military occupation was significant for hazardous noise exposure and explained many military occupations have significant noise exposure; however, the Veteran's hearing remained within normal limits during service. The audiologist reiterated that the Veteran worked in the shipyard as a sheet metal worker after service and incurred hazardous noise exposure. The audiologist reiterated there was no indication of the onset of the Veteran's hearing loss in service or within a reasonable time after separation from active duty. The audiologist concluded the Veteran's current hearing loss disability began due to noise exposure incurred after service, specifically his work as a sheet metal worker from 1979 to 1988. Though the Veteran has current bilateral sensorineural hearing loss, the preponderance of the evidence is against a finding of a linkage between the onset of the hearing loss disability and a period of service. Rather, the evidence shows that the Veteran's current bilateral hearing loss disability had no etiological relationship to in-service noise exposure. The audiologist in November 2019 acknowledged that the Veteran's military occupation was significant for hazardous noise exposure and explained many military occupations have significant noise exposure; however, the Veteran's hearing remained within normal limits during service. The audiologist explained that the Veteran worked in the shipyard as a sheet metal worker after service and incurred hazardous noise exposure. The audiologist stated there was no indication of the onset of the Veteran's hearing loss in service or within a reasonable time after separation from active duty and concluded the Veteran's current hearing loss disability began due to noise exposure incurred after service, specifically his work as a sheet metal worker from 1979 to 1988. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current hearing loss disability and a period of the Veteran's service. Additionally, there is no evidence of sensorineural hearing loss disability in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1339. No examiner in service, or since, has established chronicity or an underlying chronic disease process in service. In sum, characteristic manifestations sufficient to identify the disease (other organic disease of the nervous system) entity were not noted. Further, there is no demonstration of continuity of symptomatology or evidence of sensorineural hearing loss disability within one year of separation from service. Thus, service connection cannot be awarded on a presumptive basis. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. The Veteran is not competent to link his bilateral hearing loss disability to service. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). The Veteran is competent to state that he sustained in-service noise. However, he is a lay person and is not competent to establish that his current bilateral hearing loss disability began because of any in-service-noise exposure. The Veteran is not competent to offer an opinion as to the cause of any current bilateral hearing loss disability. The question regarding the cause of such a disability is a complex medical issue that cannot be addressed by a layperson. For these reasons, his allegations are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim of entitlement to service connection for a bilateral hearing loss disability must be denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to service connection for a disability manifested by severe cramps in the hands and legs Service connection for a hand disability (claimed arthritis) and a bilateral knee disability (claimed arthritis) was denied in the May 2019 Board decision. The Veteran did not appeal the Board decision that denied these claims. The Veteran asserts that he has a disability manifested by severe cramps in the hands and legs that began due to injury or disease sustained during service. Because there is no competent medical evidence that demonstrates that the Veteran has a disability manifested by severe cramps in the hands and legs linked to his military service, the claim will be denied. A January 1974 service treatment record documents the Veteran's complaint of persistent pain in his right hand fifth metacarpal phalangeal (MP) joint from an injury sustained two months earlier. On physical examination, the Veteran exhibited tenderness and questionable edema in the internal aspect of the MP joint. The impression was rule out (R/O) old fracture. The December 1974 service separation examination report reflects, in pertinent part, that the Veteran had leg cramps with sports. However, he had no complications or sequelae. The examiner also noted self-diagnosed arthritis of the right arm and right leg for which the Veteran never sought treatment. The May 2010 private x-ray findings showed a very mild degree of osteoarthritic changes at the distal interphalangeal (DIP) joint of the fifth digit. An April 2015 private treatment record reflects, in pertinent part, an active problem list of osteoarthritis of the hand. An October 2018 VA treatment record documents the Veteran's complaint of bilateral foot pain. He reported that he had had chronic, bilateral plantar foot pain for the past 6 to 8 years. He also complained of cramping in the bilateral feet that caused his toes to curl. He reported the cramping in his feet improved after he took oral magnesium supplements. On physical examination, the assessments, in pertinent part, were bilateral pes planus and bilateral hallux abductus. The Veteran was encouraged to follow-up with his primary care physician (PCP) for continued lower extremity cramping management. The November 2019 VA knee and lower leg conditions examination report documents diagnosis of bilateral knee degenerative arthritis. The Veteran asserted his disorder began during service after physical conditioning training during basic training. He reported that he had extremely bad leg cramps. The examiner opined that the bilateral knee degenerative arthritis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran had bilateral knee osteoarthritis that was consistent with age and degenerative changes and determined there were no medical records to support that the Veteran had osteoarthritis during service. The examiner noted that episodic leg cramps with sports, documented on the discharge examination report, was normal. The November 2019 VA hand and finger conditions examination report documents diagnosis of bilateral hand degenerative arthritis. The Veteran asserted his disorder began during service. He reported that he went on sick call because his hands hurt and that he had stiff, cold, and very sore hands. The examiner opined that the bilateral hand degenerative arthritis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran had bilateral first metacarpophalangeal (MCP) joint osteoarthritis that was consistent with age and degenerative changes and determined there were no medical records to support that the Veteran had osteoarthritis during service. The November 2019 VA muscle injuries examination report reflects that the Veteran has never been diagnosed with a muscle injury. The Veteran asserted his disorder began during service after physical conditioning training during basic training. He reported that he had extremely painful leg cramps and "charley horses." He reported that he was provided salt tablets to take during his period of service. A May 2020 VA occupational therapy initial telephone evaluation record documents diagnosis of muscle weakness. Regardless of the opinions offered by the VA examiner in November 2019 regarding the etiology of the diagnosed bilateral hand and knee degenerative arthritis, the Board reiterates that service connection for arthritis of the hands and knees was denied in the May 2019 Board decision and those claims are not currently before the Board on appeal. However, as to the claim currently on appeal, entitlement to service connection for a disability manifested by severe cramps of the hands and legs, the evidence shows that the Veteran has never been diagnosed with a muscle injury or any knee and lower leg conditions or hand and finger conditions disability (other than degenerative arthritis). The more probative evidence establishes that the Veteran does not have a disability manifested by severe cramps of the hands and legs (outside of the degenerative arthritis of the hands and knees previously adjudicated). Thus, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Further, in the November 2019 examination report, the examiner explained that episodic leg cramps with sports was normal (i.e., was not indicative of current disability). There is no competent or credible evidence or opinion that suggests that the Veteran has a current disability manifested by severe cramps in the hands and legs. The Veteran is competent to state that he had leg cramps after sports. However, he is a lay person and is not competent to establish that he has current disability manifested by severe cramps in the hands and legs that began because of any in-service injury. The Veteran is not competent to diagnose or offer an opinion as to the cause of any current upper or lower extremity disability. The question regarding the diagnosis and cause of such a disability is a complex medical issue that cannot be addressed by a layperson. For these reasons, his allegations are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim of entitlement to service connection for a disability manifested by severe cramps in the hands and legs is denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990). 3. Entitlement to service connection for a respiratory disability (claimed asthma) The Veteran claims service connection is warranted for asthma that preexisted his period of active service and was aggravated therein. Every Veteran is presumed to have been in sound condition at entry into service, except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Determination of the existence of a preexisting condition may be supported by contemporaneous evidence, or recorded history in the record, which provides a sufficient factual predicate to support a medical opinion, see Miller v. West, 11 Vet. App. 345, 348 (1998), or a later medical opinion based upon statements made by the Veteran about the pre-service history of the condition. Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000). The burden is on VA to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1094-96 (Fed. Cir. 2004). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered aggravation in service unless the underlying disability, as opposed to the symptoms of that disability, has worsened. Beverly v. Brown, 9 Vet. App. 402, 405 (1996) (citing Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991)). The February 1973 Report of Medical History associated with the Veteran's enlistment examination reflects that he had asthma at age eight. However, the February 1973 Enlistment examination reflects that clinical evaluation of the lungs and chest was normal. A July 1973 service treatment record reflects that the Veteran had a history of asthma. He reported that he was having trouble with running. He experienced chest pressure with running and would become dizzy. He reported that he found out he had asthma at age eight. He had not received treatment or been on any medication since that time. On physical examination, his lungs were clear and remained clear after five minutes of exercise. The Veteran had a cough, occasional wheezing, and sinus congestion or other upper respiratory infection (URI). The impression was probable hemolytic uremic syndrome (HUS)/URI as opposed to asthma. A September 1973 service treatment record reflects that the Veteran had a cold for two days and had a sore throat. Examination of the throat was within normal limits and the Veteran's chest was clear to percussion and auscultation (P&A). The impression was URI. A March 1974 service treatment record documents diagnosis of bronchitis. The December 1974 separation examination report reflects that clinical evaluation of the lungs and chest was normal. In pertinent part, the examiner noted that the Veteran had asthma in childhood with no complaints and no sequelae. The November 2019 VA respiratory conditions examination report documents diagnosis of restrictive lung disease. The Veteran reported that his disorder began when he was eight years old. He reported that he received treatment for complaints of inability to breathe and shortness of breath. He stated that he was given breathing treatments at that time. The examiner opined that the restrictive lung disease was less likely than not incurred in or caused by the claimed in-service injury, event, or illness and explained that in most cases childhood asthma resolves on its own and does not require further care or intervention. The examiner reported that the Veteran was diagnosed with childhood asthma before enlistment but noted that the Veteran's current diagnosis suggested a restrictive pattern, not an obstructive pattern seen in asthma. The examiner concluded that the Veteran's current restrictive lung disease was idiopathic. Further, the examiner opined that the claimed condition clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner noted that the Veteran was diagnosed with childhood asthma but explained the symptoms reported during service with running were the natural course of asthma. Regardless, the examiner reiterated that the Veteran's current restrictive lung disease suggested a restrictive pattern - not an obstructive pattern as seen in asthma and that the Veteran's restrictive lung disease was idiopathic. The presumption of soundness has been rebutted. Even though the February 1973 enlistment examination report documents that clinical evaluation of the lungs and chest was normal, the February 1973 Report of Medical History associated with his enlistment examination reflects the examiner's notation that the Veteran had asthma since age eight. The November 2019 VA examination report documents the examiner's opinion that the Veteran's preexisting asthma was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained the symptoms reported during service with running were the natural course of asthma (i.e., there is clear and unmistakable evidence that the disability was not aggravated by service). Given that the presumption of soundness has been rebutted, the Board finds that the Veteran's preexisting asthma was not aggravated during his period of service. In the November 2019 examination report, in finding that the preexisting asthma was not aggravated during service, the examiner explained the respiratory symptoms reported during service with running were the natural course of asthma. Thus, there was no increase in the disability during the Veteran's period of service. 38 C.F.R. § 3.306. In addition, the preponderance of the evidence is against a finding of a linkage between the onset of the current restrictive lung disease and a period of service. Rather, the evidence shows that the Veteran's current restrictive lung disease had no etiological relationship to in-service disease or injury. In the November 2019 examination report, the examiner explained that the Veteran's current diagnosis was indicative of a restrictive pattern not an obstructive pattern seen in asthma. Furthermore, the examiner concluded that the Veteran's current restrictive lung disease was idiopathic. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current restrictive lung disease and a period of the Veteran's service. The Veteran is competent to state that he had breathing difficulties during service. However, he is a lay person and is not competent to establish that his current restrictive lung disease began because of any in-service-injury. The Veteran is not competent to offer an opinion as to the cause of any current restrictive lung disease. The question regarding the cause of such a disability is a complex medical issue that cannot be addressed by a layperson. For these reasons, his allegations are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim of entitlement to service connection for a respiratory disability (claimed asthma) is denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Entitlement to service connection for a sleep disorder The Veteran asserts that his sleep disorder was caused or aggravated by his service-connected IBS. The service treatment records do not contain documentation of complaints of or treatment for sleep apnea or any other sleep disorder. Dated 45 years after service, the February 2019 sleep study findings show sleep apnea. The November 2019 VA sleep apnea examination report documents a diagnosis of obstructive sleep apnea. The Veteran reported that his sleep apnea began during service in 1973 manifested as insomnia. The examiner opined that the obstructive sleep apnea was less likely than not proximately due to or the result of the service-connected IBS. The examiner explained that obstructive sleep apnea was a structural collapse of the upper airway during sleep causing snoring and low oxygen and was unrelated to the rectum, hemorrhoids, or IBS. The examiner acknowledged that the Veteran cannot sleep at night and gets up to use the toilet but explained this was unrelated to obstructive sleep apnea and upper airway collapse. In addition, the examiner opined that the obstructive sleep apnea was not aggravated by the service-connected IBS. Though the Veteran has current obstructive sleep apnea, the preponderance of the evidence is against a finding of a linkage between the onset of the obstructive sleep apnea and the service-connected IBS or service-connected hemorrhoids. Rather, the evidence shows that the current obstructive sleep apnea was a structural collapse of the upper airway during sleep causing snoring and low oxygen and was unrelated to the rectum, hemorrhoids, or IBS. Though the Veteran could not sleep at night and gets up to use the toilet, this was unrelated to obstructive sleep apnea and upper airway collapse. Further, the obstructive sleep apnea was not aggravated by the service-connected IBS (See November 2019 VA examination report). This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is also no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current obstructive sleep apnea and a service-connected disability (or a period of the Veteran's service). The Veteran is competent to report his sleep disorder symptoms. However, he is a lay person and is not competent to establish that his current obstructive sleep apnea was caused or aggravated by his service-connected IBS. The Veteran is not competent to offer an opinion as to the cause of any current obstructive sleep apnea. The question regarding the cause of such a disability is a complex medical issue that cannot be addressed by a layperson. For these reasons, his allegations are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim of entitlement to service connection for a sleep disorder is denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990). 5. Entitlement to a TDIU Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or, as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. In this case, service-connection is currently in effect for IBS (30 percent disabling), anxiety disorder associated with IBS (50 percent disabling), migraines (30 percent disabling), and hemorrhoids associated with IBS (noncompensable); the combined rating for all these service-connected disabilities is 80 percent. The central inquiry is "whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). VA may consider the Veteran's education, special training, and previous work experience, but not his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. The April 2016 VA intestinal conditions examination report reflects that the Veteran's IBS does not impact his ability to work. A November 2018 statement from the Veteran's treating physician reflects that the Veteran's IBS is manifested by frequent nausea and diarrhea throughout the day. The treating physician reported that the Veteran has limited relief from medications and had been unable to work in the past because he required frequent use of bathroom facilities due to his IBS. The January 2019 VA intestinal conditions examination report reflects that the Veteran's IBS affected his ability to work because he needed to always be near a restroom. The Veteran reported that he had frequent episodes of bowel disturbances with abdominal distress and 7 or more episodes of exacerbations and/or attacks of the IBS in the past 12 months. The physician concluded that the Veteran was able to perform physical and sedentary activities of employment. The November 2019 VA rectum and anus conditions examination report reflects that the Veteran's hemorrhoids do not impact his ability to work. The November 2019 VA PTSD examination report reflects that the Veteran's anxiety disorder resulted in occupational and social impairment with reduced reliability and productivity. The November 2019 VA headaches examination report reflects that the Veteran's migraines do not impact his ability to work. A May 2020 statement from a private vocational rehabilitation counselor notes that the Veteran experienced frequent episodes of bowel disturbances with abdominal distress and 7 or more episodes of exacerbations and/or attacks of the IBS in the past 12 months (see January 2019 VA examination report). The rehabilitation counselor noted that the Veteran reported that he would have to go to the restroom 6 or 7 times consecutively and would need to go to the restroom more than 3 times per day and concluded this would have a negative effect on the ability to maintain employment. The rehabilitation counselor noted that a person would have access to restroom facilities for emergent needs during the day but that had its limits. The rehabilitation counselor stated that the Department of Labor, Wage and Hour Division Statistics for Personal Time, Fatigue and Delay showed a maximum of 3 minutes per hour off task rate as generally acceptable in the National Economy for these functions. The rehabilitation counselor concluded that work stoppage at the rate of 3 times per day with 6 or 7 episodes consecutively would not allow a person to remain in the work environment. The rehabilitation counselor also noted that the Veteran reported that his IBS was manifested by stomach cramps, pain and nausea that caused him to double over and hold his stomach with one hand which prevented him from using his hand and would impact his ability to lift or assemble things. The rehabilitation counselor concluded that substantially gainful occupation was infeasible in light of these limits. The rehabilitation counselor explained that the distractions (the result of his IBS) would hinder the Veteran's ability to remain on task and perform the complex duties required for work. The rehabilitation counselor concluded that the interfering factors of the Veteran's IBS would not allow a person to participate in substantially gainful occupation, past work, or otherwise. The January 2021 VA headaches examination report reflects that the Veteran's headaches impact his ability to work because the Veteran had difficulty focusing on tasks with headache flare-ups. The January 2021 rectum and anus conditions disability benefits questionnaire (DBQ) completed by the Veteran's treating physician reflects that the Veteran's hemorrhoids do not impact his ability to work. The Veteran's October 2018 application for a TDIU reflects, in pertinent part, that the Veteran's IBS and psychiatric disorder prevent him from securing or following a substantially gainful occupation. He reported that he last worked full-time in April 2002. He had completed 4 years of college and had no further education or training. Given the recent grant of service connection for an anxiety disorder (January 2021) and assignment of an increased rating for the migraines (February 2021), the Board finds that the evidence is in equipoise in showing that the Veteran's service-connected disabilities preclude him from realistically obtaining and maintaining any form of gainful employment, consistent with his work and education background. In the May 2020 statement, the vocational rehabilitation counselor noted that the Veteran had frequent episodes of bowel disturbances with abdominal distress and more than seven episodes of exacerbations/attacks of the IBS and reported that he would have to go to the restroom six or seven times consecutively and needed to go to the restroom more than three times per day. The rehabilitation counselor concluded that work stoppage at that rate with six or seven episodes consecutively would not allow a person to remain in the work environment. Noting the Veteran's IBS was manifested by stomach cramps, pain and nausea that caused the Veteran to double over and hold his stomach with one hand which prevented him from using his hand and would impact his ability to lift or assemble items, the rehabilitation counselor concluded that substantially gainful occupation was infeasible in light of these limits and explained that the distractions (the result of his IBS) would hinder the Veteran's ability to remain on task and perform the complex duties required for work. The rehabilitation counselor concluded that the interfering factors of the Veteran's IBS would not allow a person to participate in substantially gainful occupation, past work, or otherwise. Moreover, the November 2019 VA PTSD examination report reflects that the Veteran's anxiety disorder was productive of occupational and social impairment with reduced reliability and productivity. The January 2021 VA headaches examination report reflects that the Veteran's headaches impact his ability to work because the Veteran had difficulty focusing on tasks with headache flare-ups. In short, the evidence is in equipoise in showing the Veteran cannot sustain the stress from a competitive work environment or be expected to engage in gainful activity, consistent with his work and education background due to his service-connected disabilities (i.e., his service-connected disabilities are preventing him from maintaining substantially gainful employment). Thus, the Board finds that a grant of a TDIU rating is warranted. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.